Causes and risk factors
Among untreated violent offenders with schizophrenia, persecutory delusions are associated with violent recidivism Sheilagh Hodgins1,2 1
Département de Psychiatrie, Université de Montréal, Montréal, Canada; 2Karolinska Institutet, Stockholm, Sweden Correspondence to Sheilagh Hodgins, [email protected]
WHAT IS ALREADY KNOWN ON THIS TOPIC? A wealth of evidence shows that people with schizophrenia benefit from multiple forms of treatment.1 Specific treatments targeting antisocial and aggressive behaviour, in addition to medication and case management, have been shown to reduce the risk of violent crime.2 Yet, evidence regarding the role of positive psychotic symptoms in promoting violence is contradictory. WHAT DOES THIS PAPER ADD? ▸ This study focused on a very selective sample of individuals with schizophrenia who had been sentenced to prison for sexual or violent offences. ▸ Violence was reported by 50% of the offenders with schizophrenia who received no treatment, 27% who were treated while in prison and 25% who received treatment both in prison and after release. ▸ Aggressive behaviour is more common in acute states of psychosis than when positive symptoms are lower.3 The present study showed that among untreated offenders with schizophrenia it was one type of positive symptom, persecutory delusions, that mediated the occurrence of violence during the follow-up period. LIMITATIONS ▸ The untreated offenders with schizophrenia may have been untreated since illness onset and have presented persecutory delusions and other positive symptoms for many years. ▸ The type of treatment associated with lower rates of violence was not specified. ▸ The paper fails to reference studies published in the past 15 years showing that when offenders with schizophrenia participate in a coordinated programme of supervision, treatment with antipsychotic medication, and cognitive–behavioural treatments for antisocial and aggressive behaviour violence is reduced.2 WHAT NEXT IN RESEARCH? ▸ Studies are needed to answer the following questions:
A. Among patients presenting persecutory delusions what characteristics distinguish those who behave violently? B. Which antipsychotic best reduces persecutory delusions? C. In some patients, do persecutory delusions persist despite treatment with antipsychotic medications? D. Would CBT contribute to reducing persecutory delusions? E. Would preventing the use of alcohol and illicit drugs by people with schizophrenia prevent persecutory delusions? COULD THESE RESULTS CHANGE YOUR PRACTICES AND WHY? Persons with schizophrenia who refuse treatment put themselves and others at risk for multiple negative outcomes. Therefore mental health practitioners, and policy makers, need to make every effort to convince them to engage in treatment. This means helping patients and their families understand the importance of taking antipsychotic medications, and providing patients with the supports necessary to begin, and to continue, taking medications. Further, it is essential to assess patients’ risk to engage in violence, especially among those with histories of violence, periods without antipsychotic medications and with elevated levels of positive psychotic symptoms including persecutory delusions. Competing interests None. doi:10.1136/eb-2014-101859
REFERENCES 1. 2.
3.
Lieberman JA, Murray RM. Comprehensive care of schizophrenia: a textbook of clinical management. New York: Oxford University Press, 2012. Kolla N, Hodgins S. Treatment of people with schizophrenia who behave violently towards others: a review of the empirical literature on treatment effectiveness. In: Craig LA, Dixon L, Gannon TA Eds. What works in offender rehabilitation: an evidence based approach to assessment and treatment. Wiley Blackwell, 2013:319–39. Hodgins S, Riaz M. Violence and phases of illness: differential risk and predictors. Eur Psychiatry 2011;26:518–24.
Patients/participants 1717 adult male and female offenders serving a minimum of 2 years for a sexual or violent offense and due for release during the 12-month recruitment period. Setting England and Wales Prisoner Cohort Study; recruitment June 2001 to June 2002. Exposure A baseline assessment was made prior to release to assess for lifetime diagnosis of psychotic illness, psychiatric treatment during the current sentence and patients’ self-report of four psychotic symptoms (hallucinations, thought interference, strange experiences and persecutory delusions). Follow-up assessment after release included self-report of psychotic symptoms in the previous 3 months, and any psychiatric treatment. Information on violent behaviour since release was obtained through self-report and convictions recorded in the Police National Computer. Comparison Offenders with no history of psychosis. Follow-up period Mean 39.2 weeks (SD 33).
men. Of those followed up, 94 had schizophrenia (9.9%), 29 had delusional disorder (3.0%) and 102 had drug-induced psychosis (10.7%). Psychotic disorder Compared to people with no history of psychosis (n=742), presence of a psychotic disorder was not significantly associated with violent reoffending after adjusting for covariates including drug and alcohol dependence. Untreated schizophrenia People with untreated schizophrenia had a significantly increased risk of violence compared to those with continuous or discontinuous treatment for schizophrenia (OR=3.33, 95% CI 1.03 to 10.75), or people with no history of psychosis (OR=3.43, 95% CI 1.10 to 10.72). Persecutory delusions People with persecutory delusions were significantly more likely to be violent (OR=3.42, 95% CI 2.19 to 5.33). Mediation analyses found that persecutory delusions significantly accounted for the association between violence and untreated schizophrenia (β=0.02, 95% CI 0.01 to 0.04). There was no significant association with psychotic symptoms of hallucinations, thought insertion or strange experiences.
OUTCOMES Study population Nine hundred and sixty-seven participants were successfully followed up (56.3%). Mean age was 30.9 years and 81.4% of participants were
Evid Based Mental Health August 2014 Vol 17 No 3
75
Commentary on
ABSTRACT FROM: Keers R, Ullrich S, DeStavola BL, et al. Association of violence with emergence of persecutory delusions in untreated schizophrenia. Am J Psychiatry 2014;171:332–9.
Copyright of Evidence Based Mental Health is the property of BMJ Publishing Group and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
Among untreated violent offenders with schizophrenia, persecutory delusions are associated with violent recidivism Sheilagh Hodgins1,2 1
Département de Psychiatrie, Université de Montréal, Montréal, Canada; 2Karolinska Institutet, Stockholm, Sweden Correspondence to Sheilagh Hodgins, [email protected]
WHAT IS ALREADY KNOWN ON THIS TOPIC? A wealth of evidence shows that people with schizophrenia benefit from multiple forms of treatment.1 Specific treatments targeting antisocial and aggressive behaviour, in addition to medication and case management, have been shown to reduce the risk of violent crime.2 Yet, evidence regarding the role of positive psychotic symptoms in promoting violence is contradictory. WHAT DOES THIS PAPER ADD? ▸ This study focused on a very selective sample of individuals with schizophrenia who had been sentenced to prison for sexual or violent offences. ▸ Violence was reported by 50% of the offenders with schizophrenia who received no treatment, 27% who were treated while in prison and 25% who received treatment both in prison and after release. ▸ Aggressive behaviour is more common in acute states of psychosis than when positive symptoms are lower.3 The present study showed that among untreated offenders with schizophrenia it was one type of positive symptom, persecutory delusions, that mediated the occurrence of violence during the follow-up period. LIMITATIONS ▸ The untreated offenders with schizophrenia may have been untreated since illness onset and have presented persecutory delusions and other positive symptoms for many years. ▸ The type of treatment associated with lower rates of violence was not specified. ▸ The paper fails to reference studies published in the past 15 years showing that when offenders with schizophrenia participate in a coordinated programme of supervision, treatment with antipsychotic medication, and cognitive–behavioural treatments for antisocial and aggressive behaviour violence is reduced.2 WHAT NEXT IN RESEARCH? ▸ Studies are needed to answer the following questions:
A. Among patients presenting persecutory delusions what characteristics distinguish those who behave violently? B. Which antipsychotic best reduces persecutory delusions? C. In some patients, do persecutory delusions persist despite treatment with antipsychotic medications? D. Would CBT contribute to reducing persecutory delusions? E. Would preventing the use of alcohol and illicit drugs by people with schizophrenia prevent persecutory delusions? COULD THESE RESULTS CHANGE YOUR PRACTICES AND WHY? Persons with schizophrenia who refuse treatment put themselves and others at risk for multiple negative outcomes. Therefore mental health practitioners, and policy makers, need to make every effort to convince them to engage in treatment. This means helping patients and their families understand the importance of taking antipsychotic medications, and providing patients with the supports necessary to begin, and to continue, taking medications. Further, it is essential to assess patients’ risk to engage in violence, especially among those with histories of violence, periods without antipsychotic medications and with elevated levels of positive psychotic symptoms including persecutory delusions. Competing interests None. doi:10.1136/eb-2014-101859
REFERENCES 1. 2.
3.
Lieberman JA, Murray RM. Comprehensive care of schizophrenia: a textbook of clinical management. New York: Oxford University Press, 2012. Kolla N, Hodgins S. Treatment of people with schizophrenia who behave violently towards others: a review of the empirical literature on treatment effectiveness. In: Craig LA, Dixon L, Gannon TA Eds. What works in offender rehabilitation: an evidence based approach to assessment and treatment. Wiley Blackwell, 2013:319–39. Hodgins S, Riaz M. Violence and phases of illness: differential risk and predictors. Eur Psychiatry 2011;26:518–24.
Patients/participants 1717 adult male and female offenders serving a minimum of 2 years for a sexual or violent offense and due for release during the 12-month recruitment period. Setting England and Wales Prisoner Cohort Study; recruitment June 2001 to June 2002. Exposure A baseline assessment was made prior to release to assess for lifetime diagnosis of psychotic illness, psychiatric treatment during the current sentence and patients’ self-report of four psychotic symptoms (hallucinations, thought interference, strange experiences and persecutory delusions). Follow-up assessment after release included self-report of psychotic symptoms in the previous 3 months, and any psychiatric treatment. Information on violent behaviour since release was obtained through self-report and convictions recorded in the Police National Computer. Comparison Offenders with no history of psychosis. Follow-up period Mean 39.2 weeks (SD 33).
men. Of those followed up, 94 had schizophrenia (9.9%), 29 had delusional disorder (3.0%) and 102 had drug-induced psychosis (10.7%). Psychotic disorder Compared to people with no history of psychosis (n=742), presence of a psychotic disorder was not significantly associated with violent reoffending after adjusting for covariates including drug and alcohol dependence. Untreated schizophrenia People with untreated schizophrenia had a significantly increased risk of violence compared to those with continuous or discontinuous treatment for schizophrenia (OR=3.33, 95% CI 1.03 to 10.75), or people with no history of psychosis (OR=3.43, 95% CI 1.10 to 10.72). Persecutory delusions People with persecutory delusions were significantly more likely to be violent (OR=3.42, 95% CI 2.19 to 5.33). Mediation analyses found that persecutory delusions significantly accounted for the association between violence and untreated schizophrenia (β=0.02, 95% CI 0.01 to 0.04). There was no significant association with psychotic symptoms of hallucinations, thought insertion or strange experiences.
OUTCOMES Study population Nine hundred and sixty-seven participants were successfully followed up (56.3%). Mean age was 30.9 years and 81.4% of participants were
Evid Based Mental Health August 2014 Vol 17 No 3
75
Commentary on
ABSTRACT FROM: Keers R, Ullrich S, DeStavola BL, et al. Association of violence with emergence of persecutory delusions in untreated schizophrenia. Am J Psychiatry 2014;171:332–9.
Copyright of Evidence Based Mental Health is the property of BMJ Publishing Group and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
